APPLICATION FOR BUILDING PERMIT

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1 APPLICATION FOR BUILDING PERMIT Project Location: Section/Block/Lot: Zone: Legal Address: Owner s Name and Address: Owner s Phone: Owner s Alt Phone: Project Information: Current Use of Property/Building: Proposed Use of Property/Building: Nature of Construction: New Building Conversion Demolition Pool Addition Alteration Other Existing Sqft: Additional/New Sqft Total Sqft Water Service: Well Public Sewer: Public Septic Project Description: Estimated Value of Construction: Application must include 2 copies of proposed building plans and a survey showing setback dimensions. If value is over $20,000.00, plans must be signed and sealed by a NYS Engineer or Architect. Application must be signed on page 3 by Property Owner or a completed and notarized APPLICATION OF A PROPERTY AGENT form must be submitted with the APPLICATION FOR BUILDING PERMIT. 277 Old Nyack Turnpike, Chestnut Ridge, NY (845) FAX (845)

2 Village of Chestnut Ridge Building Permit Application General Contractor Information: Name Phone Address Electrical Contractor Information: Name Phone Address Plumbing Contractor Information: Name Phone Address Mechanical Contractor Information: Name Phone Address All Contractors must submit: Copy of a valid Rockland County License Contractors Liability Certificate of Insurance All Contractors with (1) or more employees must submit: DB120.1 or DB155 Disability Benefits Certificate C105.2 or U26.3 or SI 12 Workers Compensation Certificate All Contractors with (0) employees may submit: CE 200 Certificate of Attestation of Exemption from NYS Workers Compensation and/or Disability Benefits Insurance Coverage form Certificate Holder on Certificate of Insurance must be written as follows: Village of Chestnut Ridge 277 Old Nyack Turnpike Chestnut Ridge, NY Old Nyack Turnpike, Chestnut Ridge, NY (845) FAX (845)

3 Village of Chestnut Ridge Building Permit Application BUILDING PERMIT FEE SCHEDULE (ALL FEES ARE DUE AT THE TIME OF APPLICATION) New one and two family dwellings: $ for the first $1, of construction value $11.00 for each additional $1,000.00, or fraction thereof $ for Certificate of Occupancy Additions, alterations, accessory structures, demolition of one and two family dwellings: $ for the first $1, of construction value $9.00 for each additional $1,000.00, or fraction thereof $50.00 for Certificate of Occupancy New Construction or alterations, repairs, additions, accessory buildings, or structures, demolition, plumbing, etc. for other than one and two family dwellings $ for the first $25, of construction costs $ for the next $25, of construction costs $ for the next $50, of construction costs $ for the next $50, of construction costs $9.00 for each additional $1,000.00, or fraction thereof $ for Certificate of Occupancy or Use Applicant s Signature: Contact Address: Contact Phone Number: For Building Department Use Zone Value $ Permit Number Permit Issued C/O Issued Permit Fee $ C/O Fee $ Total $ Variance Received Variance Number Permit Granted for, Date Building Inspector Building Inspector 277 Old Nyack Turnpike, Chestnut Ridge, NY (845) FAX (845)

4 Affidavit of Ownership for the following property: AFFIDAVIT OF OWNERSHIP Section Block Lot Address: (No PO Box Accepted) City: Chestnut Ridge State: New York Zip Code: Property Owner: Last Name: First Name: Address: (No PO Boxes Accepted) City: State: Zip: Primary Phone Number: Secondary Phone Number: Note: Non-individuals, (i.e, Partnerships, LLC, S-Corp, Corporations, etc.) must submit supporting documentation establishing ownership. Rev 8/4/2014 Page 1 of 2

5 Village of Chestnut Ridge Affidavit of Ownership State of New York County of Rockland Ss: I being duly sworn, deposes and says that I am the owner and fee of all that certain lot, parcel of land, in the Village of Chestnut Ridge, as designated on the Town of Ramapo Tax Map as: Section, Block, Lot. Signature of Owner Sworn to before me this day of, 20 Notary Public Seal Rev 8/4/2017 Page 2 of 2

6 Village of Chestnut Ridge Building Permit Application THE FOLLOWING INSPECTIONS ARE REQUIRED AND MUST BE SCHEDULED 1. Footing Form: when excavation is complete and forms are in place (prior to concrete). 2. Foundation: prior to backfill, check for type of foundation, footing drains and waterproofing. 3. Plumbing Under Slab: prior to pour, usually combined with gravel under slab. 4. Gravel Under Slab: all vapor barriers, wire and insulation in place. 5. Framing: electrical inspection for rough in must be complete prior to this inspection. 6. Plumbing Rough: can be combined with framing, head and air tests in place. 7. Mechanical Rough: can be combined with framing and plumbing 8. Insulation: all fire stopping must be installed. 9. Footing Drain Outlet 10. Grading 11. Final: final electrical inspection must be completed prior to scheduling. In addition all commercial buildings must have inspections by Village Engineer for site plan compliance and erosion control and Fire Safety Inspections prior to the issuance of a Certificate of Use. 277 Old Nyack Turnpike, Chestnut Ridge, NY (845) FAX (845)

7 LOCAL LAW NO. 26 OF 1987 REQUIRES ALL NON-RESIDENT OWNERS AND CERTAIN LESSEES OF LANDS LOCATED WITHIN THE CONFINES OF THE VILLAGE OF CHESTNUT RIDGE TO DESIGNATE AN AUTHORIZED REPRESENTATIVE. The Village of Chestnut Ridge Building Department requires proof of authority before acceptance of a signature on any Building Department transaction. If the signer is not the property owner listed on the current Village Tax Roll then sufficient documentation must be submitted to establish them as having legal authority to represent the property owner. Designation for the following property: Section Block Lot Address: (No PO Box Accepted) City: Chestnut Ridge State: New York Zip Code: Rev 9/11/2017 Page 1 of 4

8 Village of Chestnut Ridge Authorized Representative Designation Form Property Owner: Last Name: First Name: Date of Birth (DOB): Address: (No PO Boxes Accepted) City: State: Zip: Primary Phone Number: Secondary Phone Number: Authorized Representative Last Name: First Name: Date of Birth (DOB): Address: (No PO Boxes Accepted) City: State: Zip: Primary Phone Number: Secondary Phone Number: Rev 9/11/2017 Page 2 of 4

9 Village of Chestnut Ridge Authorized Representative Designation Form Homeowner Affidavit I, designate Name of Property Owner Print name of Authorized Representative as my authorized representative and affirm that all information and statements are true and complete to the best of my knowledge. Signature of Property Owner Notary Certification: State of County of I certify that on the date set forth below the individual(s) named above did appear personally before me and that I did identify the applicant by comparing the applicant s signature and DOB on his/her identifying document. The statements and documents are subscribed and sworn to before me by the applicant on this date: / / MM DD yyyy Signature of Notary Public Notary ID Number: Expiration Date: (SEAL) Rev 9/11/2017 Page 3 of 4

10 Village of Chestnut Ridge Authorized Representative Designation Form Authorized Representative Affidavit I, agree to act as the authorized representative in all Print Name of Authorized Representative Matters concerning the management and operation of the above listed property, in relation to the Village of Chestnut Ridge, including but not limited to, the acceptance of service of notices and process and affirm that all information and statements are true and complete to the best of my knowledge. Signature of Authorized Representative Notary Certification: State of County of I certify that on the date set forth below the individual(s) named above did appear personally before me and that I did identify the applicant by comparing the applicant s signature and DOB on his/her identifying document. The statements and documents are subscribed and sworn to before me by the applicant on this date: / / MM DD yyyy Signature of Notary Public Notary ID Number: Expiration Date: (SEAL) Rev 9/11/2017 Page 4 of 4

11 AFFIDAVIT FINAL COST OF CONSTRUCTION State of New York County of Rockland ss.:, being duly sworn, deposes and says that he/she is the Applicant or Agent of the Applicant named in the Application for a Building Permit dated, relating to construction or other work to be performed on, or in connection with the premises located at the following address: ; that the estimated stated in said application of the construction or other work described therein was Dollars ($ ); that the actual final cost of such construction or other work was Dollars ($ ) and that said construction or other work was performed in accordance with the applicable provisions of the law. Signature Sworn to before me this day of, 20 Notary Public For Official Use Only: Permit Number: Field Cost: Permit Fee Paid: Additional Fee: $ $ $ Costs for the work described in the Application for Building Permit includes the cost of all the construction and other work done in connection therewith, exclusive of the cost of the land, if the final cost is less than the estimated cost stated in the Application for Building Permit, no portion of the fees paid upon the filing of the application will be refunded. 277 Old Nyack Turnpike, Chestnut Ridge, NY 10977, (845) Fax (845)

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